| 1. |
- Broms, Jacob, et al.
(författare)
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Prehospital tracheal intubations by anaesthetist-staffed critical care teams: a prospective observational multicentre study
- 2023
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Ingår i: BRITISH JOURNAL OF ANAESTHESIA. - 0007-0912 .- 1471-6771. ; 131:6, s. 1102-1111
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Tidskriftsartikel (refereegranskat)abstract
- Background: Prehospital tracheal intubation is a potentially lifesaving intervention, but is associated with prolonged time on-scene. Some services strongly advocate performing the procedure outside of the ambulance or aircraft, while others also perform the procedure inside the vehicle. This study was designed as a non-inferiority trial registering the rate of successful tracheal intubation and incidence of complications performed by a critical care team either inside or outside an ambulance or helicopter.Methods: This observational multicentre study was performed between March 2020 and September 2021 and involved 12 anaesthetiststaffed critical care teams providing emergency medical services by helicopter in Denmark, Norway, and Sweden. The primary outcome was first-pass successful tracheal intubations.Results: Of the 422 drug-assisted tracheal intubations examined, 240 (57%) took place in the cabin of the ambulance or helicopter. The rate of first-pass success was 89.2% for intubations in-cabin vs 86.3% outside. This difference of 2.9% (confidence interval -2.4% to 8.2%) (two sided 10%, including 0, but not the non-inferiority limit D=-4.5) fulfils our criteria for non-inferiority, but not significant superiority. These results withstand after performing a propensity score analysis. The mean on-scene time associated with the helicopter in-cabin procedures (27 min) was significantly shorter than for outside the cabin (32 min, P=0.004).Conclusions: Both in-cabin and outside the cabin, prehospital tracheal intubation by anaesthetists was performed with a high success rate. The mean on-scene time was shorter in the in-cabin helicopter cohort.
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| 2. |
- Dillenbeck, Emelie, et al.
(författare)
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The design of the PRINCESS 2 trial: A randomized trial to study the impact of ultrafast hypothermia on complete neurologic recovery after out-of-hospital cardiac arrest with initial shockable
- 2024
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Ingår i: American Heart Journal. - : MOSBY-ELSEVIER. - 0002-8703 .- 1097-6744. ; 271, s. 97-108
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Tidskriftsartikel (refereegranskat)abstract
- Background Delayed hypothermia, initiated after hospital arrival, several hours after cardiac arrest with 8-10 hours to reach the target temperature, is likely to have limited impact on overall survival. However, the effect of ultrafast hypothermia, i.e., delivered intra-arrest or immediately after return of spontaneous circulation (ROSC), on functional neurologic outcome after out -of -hospital cardiac arrest (OHCA) is unclear. In two prior trials, prehospital trans -nasal evaporative intra-arrest cooling was safe, feasible and reduced time to target temperature compared to delayed cooling. Both studies showed trends towards improved neurologic recovery in patients with shockable rhythms. The aim of the PRINCESS2-study is to assess whether cooling, initiated either intra-arrest or immediately after ROSC, followed by in -hospital hypothermia, significantly increases survival with complete neurologic recovery as compared to standard normothermia care, in OHCA patients with shockable rhythms. Methods/design In this investigator -initiated, randomized, controlled trial, the emergency medical services (EMS) will randomize patients at the scene of cardiac arrest to either trans -nasal cooling within 20 minutes from EMS arrival with subsequent hypothermia at 33 degrees C for 24 hours after hospital admission (intervention), or to standard of care with no prehospital or in -hospital cooling (control). Fever ( > 37,7 degrees C) will be avoided for the first 72 hours in both groups. All patients will receive post resuscitation care and withdrawal of life support procedures according to current guidelines. Primary outcome is survival with complete neurologic recovery at 90 days, defined as modified Rankin scale (mRS) 0-1. Key secondary outcomes include survival to hospital discharge, survival at 90 days and mRS 0-3 at 90 days. In total, 1022 patients are required to detect an absolute difference of 9% (from 45 to 54%) in survival with neurologic recovery (80% power and one-sided alpha= 0,025, beta = 0,2) and assuming 2,5% lost to follow-up. Recruitment starts in Q1 2024 and we expect maximum enrolment to be achieved during Q4 2024 at 20-25 European and US sites. Discussion This trial will assess the impact of ultrafast hypothermia applied on the scene of cardiac arrest, as compared to normothermia, on 90 -day survival with complete neurologic recover y in OHCA patients with initial shockable rhythm. Trial registration NCT06025123. (Am Heart J 2024;271:97-108.)
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| 3. |
- Gellerfors, Mikael
(författare)
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Prehospital advanced airway management in the Nordic countries
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Tracheal intubation (TI) is often the preferred technique to secure the airway of an unconscious patient in the prehospital setting. Prehospital TI is associated with several challenges, including limited assistance, few airway rescue devices and environmental difficulties. An example of the latter is the occasional need for TI inside the cabin of an ambulance helicopter. The Nordic countries consist of both rural and urban areas with typically cold subarctic climate. The region is characterized by almost exclusive use of airway experts, mainly anaesthetists, for prehospital TI. The overall aim was to investigate prehospital advanced airway management in Nordic countries with regard to success rates, times, providers and techniques. Study I: A retrospective observational study of all patients intubated out-of-hospital with the device Airtraq® in Stockholm 2008-2012. A total number of 2453 patients were intubated during the study period and Airtraq® was used in 28 (1.1%) cases. Sixty-eight percent (19/28) of the Airtraq® intubation attempts were successful. When used due to an anticipated or unexpected difficult airway, the success rate was 61% (14/23). Study II: An experimental prospective randomized crossover manikin study on anaesthetist TI was conducted in a military helicopter cabin in daylight or darkness with night vision goggles (NVG) or in a daylight emergency department (ED) setting. The TI success rate was 100% in all scenarios. The in-cabin helicopter TI time was shorter in daylight vs. darkness with NVG (16.5 s vs. 30.0 s; p=0.03). There was no difference in TI time between the helicopter cabin daylight and ED setting (16.5 vs. 16.8 s; p=0.91). There was no difference in either glottic visualization (CL 2.0 vs. 1.8; p=0.72) or perceived intubation difficulty (VAS 3.0 vs. 2.8; p=0.24) between the daylight helicopter and ED scenarios. Study III: A prospective observational study of advanced airway management by twelve second-tier prehospital critical care teams in the Nordic countries was conducted from May 2015 to November 2016. Data were collected from six ambulance helicopters and six rapid response cars using the standardized Utstein-style airway template. During the study period, 2028 patients were intubated due to cardiac arrest (53.0%), other medical conditions (26.3%) and trauma (19.1%). The majority (67.0%) of the TIs were performed by providers who had intubated >2500 patients. The overall TI success rate was 98.7%, with a first pass success rate of 84.5% and overall complication rate of 10.9%. The median TI time was 25 s (IQR 15-30 s), and the time on scene was 25 min (IQR 18-33 min). The TI success rate was higher among physicians compared with nurses (99.0% vs. 97.6%; p=0.03). Study IV: An experimental prospective randomized crossover manikin study of in-cabin vs. outside helicopter cabin TI was conducted by 14 anaesthetists. The success rate was 100%, with all TIs being successful on the first attempt. There was no difference in glottic visualization (CL 1.0 vs. 1.0), but the participants perceived the in-cabin TI to be easier than intubating outside the helicopter cabin (VAS 1 vs. VAS 2; p=0.02). The total on-scene time was significantly shorter using the in-cabin TI strategy compared with the standard outside TI (266 vs. 320 s; p=0.04). In conclusion, prehospital TI is almost exclusively performed by very experienced airway providers in the Nordic countries. In this setting, the prehospital TI success rate is high and associated with few complications, comparable to in-hospital standards. The TI procedure is fast with a short on-scene time, which may benefit patients with time-critical emergencies, such as multitrauma and traumatic brain injuries. There may be potential to further decrease on-scene times with the in-cabin TI concept. The first-pass TI success rate was higher with video laryngoscopy compared with direct laryngoscopy, but the Airtraq® is not a suitable prehospital indirect laryngoscope. There is a need for large randomized studies to better investigate different aspects of the prehospital advanced airway management.
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| 4. |
- Renberg, Mattias, et al.
(författare)
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Prehospital and emergency department airway management of severe penetrating trauma in Sweden during the past decade
- 2023
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Ingår i: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. - : BioMed Central (BMC). - 1757-7241. ; 31:1
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Tidskriftsartikel (refereegranskat)abstract
- Background Prehospital tracheal intubation (TI) is associated with increased mortality in patients with penetrating trauma, and the utility of prehospital advanced airway management is debated. The increased incidence of deadly violence in Sweden warrants a comprehensive evaluation of current airway management for patients with penetrating trauma in the Swedish prehospital environment and on arrival in the emergency department (ED).Methods This was an observational, multicenter study of all patients with penetrating trauma and injury severity scores (ISSs) >= 15 included in the Swedish national trauma register (SweTrau) between 2011 and 2019. We investigated the frequency and characteristics of prehospital and ED TI, including 30-day mortality and patient characteristics associated with TI.Result Of 816 included patients, 118 (14.5%) were intubated prehospitally, and 248 (30.4%) were intubated in the ED. Patients who were intubated prehospitally had a higher ISS, 33 (interquartile range [IQR] 25, 75), than those intubated in the ED, 25 (IQR 18, 34). Prehospital TI was associated with a higher associated mortality, OR 4.26 (CI 2.57, 7.27, p < 0.001) than TI in the ED, even when adjusted for ISS (OR 2.88 [CI 1.64, 5.14, p < 0.001]). Hemodynamic collapse (<= 40 mmHg) and low GCS score (<= 8) were the characteristics most associated with prehospital TI. Traumatic cardiac arrests (TCAs) occurred in 154 (18.9%) patients, of whom 77 (50%) were intubated prehospitally and 56 (36.4%) were intubated in the ED. A subgroup analysis excluding TCA showed that patients with prehospital TI did not have a higher mortality rate than those with ED TI, OR 2.07 (CI 0.93, 4.51, p = 0.068), with OR 1.39 (0.56, 3.26, p = 0.5) when adjusted for ISS.Conclusion Prehospital TI was associated with a higher mortality rate than those with ED TI, which was specifically related to TCA; intubation did not affect mortality in patients without cardiac arrest. Mortality was high when airway management was needed, regardless of cardiac arrest, thereby emphasizing the challenges posed when anesthesia is needed. Several interventions, including whole blood transfusions, the implementation of second-tier EMS units and measures to shorten scene times, have been initiated in Sweden to counteract these challenges.
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| 5. |
- Renberg, Mattias, et al.
(författare)
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Prehospital transportation of severe penetrating trauma victims in Sweden during the past decade : a police business?
- 2023
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Ingår i: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. - : BioMed Central (BMC). - 1757-7241. ; 31:1
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Tidskriftsartikel (refereegranskat)abstract
- IntroductionSweden is facing a surge of gun violence that mandates optimized prehospital transport approaches, and a survey of current practice is fundamental for such optimization. Management of severe, penetrating trauma is time sensitive, and there may be a survival benefit in limiting prehospital interventions. An important aspect is unregulated transportation by police or private vehicles to the hospital, which may decrease time but may also be associated with adverse outcomes. It is not known whether transport of patients with penetrating trauma occurs outside the emergency medical services (EMS) in Sweden and whether it affects outcome.MethodThis was a retrospective, descriptive nationwide study of all patients with penetrating trauma and injury severity scores (ISSs) ≥ 15 registered in the Swedish national trauma registry (SweTrau) between June 13, 2011, and December 31, 2019. We hypothesized that transport by police and private vehicles occurred and that it affected mortality.ResultA total of 657 patients were included. EMS transported 612 patients (93.2%), police 10 patients (1.5%), and private vehicles 27 patients (4.1%). Gunshot wounds (GSWs) were more common in police transport, 80% (n = 8), compared with private vehicles, 59% (n = 16), and EMS, 32% (n = 198). The Glasgow coma scale score (GCS) in the emergency department (ED) was lower for patients transported by police, 11.5 (interquartile range [IQR] 3, 15), in relation to EMS, 15 (IQR 14, 15) and private vehicles 15 (IQR 12.5, 15). The 30-day mortality for EMS was 30% (n = 184), 50% (n = 5) for police transport, and 22% (n = 6) for private vehicles. Transport by private vehicle, odds ratio (OR) 0.65, (confidence interval [CI] 0.24, 1.55, p = 0.4) and police OR 2.28 (CI 0.63, 8.3, p = 0.2) were not associated with increased mortality in relation to EMS.ConclusionNon-EMS transports did occur, however with a low incidence and did not affect mortality. GSWs were more common in police transport, and victims had lower GCS scorescores when arriving at the ED, which warrants further investigations of the operational management of shooting victims in Sweden.
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